IMPORTANT NOTICE

CLAIM FORM – TRAVEL INSURANCE

Filing a claim

Complete the claim form(s) and sign where designated with an X. Each person who received healthcare services must complete a claim form. The form must be signed by the beneficiary (person who received healthcare services). If the claim involves a minor, the

policyholder must sign the form.

Attach all the following documents: Original itemized bills for all healthcare services received, the diagnosis and treatment must appear clearly . Original prescription drug receipts showing the name of the drug, the dosage and the price. Proof of payment for all expenses claimed, such as a credit card statement or proof of a deposited cheque showing the

currency in which the service was paid. In the absence of a bank or credit card statement, a receipt may be accepted. Proof of your departure and return dates, such as a plane ticket, a stamped copy of your passport, a bank or credit card

statement showing purchases made in Canada just before your departure date and immediately after your return. Any other relevant document(s), such as medical reports, lab results, etc.

Make copies of all submitted documents for your files, as they will not be returned.

Send the completed forms and all other required documents by mail to:

Quebec :CanAssistanceTravel Claims Department1981, McGill College Avenue, Suite 400Montreal, Quebec H3A 2W9

Ontario :CanAssistanceTravel Claims DepartmentP.O. Box 4439, Station AToronto (Ontario) M5W 3Z4

Additional Information

Your claim will be reviewed as quickly as possible once we’ve received the required documents. The following situations may increase the time it takes us to process your claim:

An incomplete claim form or missing document Delayed or missing detailed invoice Delayed or missing medical information

Eligible expenses are reimbursed in Canadian funds by cheque made out to the policyholder. If you’re covered by more than one travel insurance policy, indicate this on your claim form. We will work with your other insurer to coordinate your benefits as needed. 

If you receive a bill, please do not make any payments directly to the service provider unless we instruct you to do so. Simply send it to the address above.

Should you have any questions about your claim, please contact our customer service at 514 286‐8336 or toll‐free at 1 800 264‐1852 Monday through Friday from 8:30 am to 5:00 pm or by email at claims@canassistance.com. 

A duly completed and signed claim form is necessary even if you haven’t made any payments. Your public health insurance plan covers some of the fees for medical care received during your trip. CanAssistance reimburses these fees in full, but must submit them to your provincial health insurance plan.

In accordance to the terms of your contract, by signing the form you authorize CanAssistance to: Access your personal and medical information required to adjudicate your claim Pay eligible expenses to service providers directly

Failure to return the duly completed form entitles CanAssistance to ask you to refund the fees paid on your behalf.

01CAN0031A (11-19

)

CLAIM PROCESS

MANDATE

A photocopy or a fax of this authorization shall be considered as valid as the original

SIGNATURE OF THE BENEFICIARY

PLEASE COMPLETE AND SIGN THE BACK OF THIS FORM

INSURER’S NAME

CONTRACT NO.

(Optional) GROUP NO.

(Optional) FILE NO.

CLAIM FORM – TRAVEL INSURANCE

X

01

QR

V0

01

3B

-A (12

-19)

1. I, the undersigned (please print)_________________________________________________________________________Authorize CanAssistance inc. and its signing officers as my attorneys to receive in my name and endorse and negotiate onmy behalf, cheques and other forms of payment from my provincial or territorial health insurance plan (OHIP) for thereimbursement of claims relating to hospital and medical services incurred during a trip outside my place of residenceduring my coverage period, including any authorized extension of such coverage, and in accordance with my travelinsurance plan.

2. I irrevocably direct and authorize OHIP to make payment in respect of my claim for health services incurred during suchtrip to CanAssistance inc. directly and I hereby release OHIP, upon payment to CanAssistance inc. from any further claim orcause of action in connection therewith.

3. I hereby consent and authorize Canassistance Inc. and OHIP to directly or indirectly collect information contained in theclaim and source documents pursuant to applicable provincial legislation.

4. I consent to the disclosure by OHIP to CanAssistance inc. of such personal information as may be necessarily requiredfor the processing of my claim for such health services, including the details of any duplicate payment previously madedirectly to me.

5. I hereby agree to assign to CanAssistance Inc. all benefits payable by third parties for losses covered under the policy.Furthermore, following the application for reimbursement from CanAssistance Inc., I authorize third parties to payCanAssistance Inc., the benefits payable regarding these losses.

6. I authorize CanAssistance Inc. to provide the information contained in my claim file to third parties, for their use, withinthe context of this claim, to determine the benefits payable, if the case arises.

7. I certify that the information contained herein is true and complete to the best of my knowledge and I hereby authorizeany licensed physician, practitioner, hospital or medical institution, insurance company, OHIP, the Medical InformationBureau or any other agency, institution or person who has information or documents about me or a member of my family,or my state of health or that of a member of my family (including all previous medical reports) to convey that informationor forward those documents to CanAssistance Inc.

BENEFICIARY

Provincial Health Insurance Card No.

LETTERS(Version Code)

NUMBERS

LAST NAME (as appearing on health insurance card) FIRST NAME (as appearing on health insurance card)

DATE

If not the beneficiary, relationship (father, mother, etc.):

GENDER

M

Month Day

F

DATE OF BIRTH Year

TELEPHONE - HOME CELLPHONE

A. Fill out the insurer’s name and the contract number (certificate). If available, you can fill out the group number and the file number;B. Complete both sides and SIGN THE CLAIM FORM;C. Indicate your Ontario health insurance number with the version code (one or two letters on your health card) to avoid delays in processing your claim;D. Keep a copy of all documents for your records and send in the originals to the following address: CANASSISTANCE - TRAVEL CLAIMS DEPARTMENT

P.O. BOX 4439, STATION A TORONTO, ONTARIO M5W 3Z4

FOR OFFICE USE

CLAIM FORM – TRAVEL INSURANCE

CONTRACT HOLDER (IF DIFFERENT FROM THE BENEFICIARY)

DATE OF BIRTH GENDER

M

Year Month Day

1Home address in Ontario No STREET

POSTAL CODE TELEPHONE

SEND CHEQUE TO: SEND CORRESPONDENCE TO:ADDRESS

E-MAIL:

STAY OUTSIDE ONTARIO

Trip during which you received healtcare services

Date of departure

Year Month Day

Date of return in OntarioActual

Reason for trip (check one box only)

Vacation or seasonal absence

Work Employer’s name:

StudiesInclude a written certificate from the institution indicating the dates of the beginning and end of your courses

Receive medical care If you made a request of authorization to the OHIP, indicate the number

Other Specify:

HEALTHCARE SERVICES OUTSIDE ONTARIO

Indicate why you received healthcare services:

In the case of an accident, specify the type of accident:

Date of the accidentMotor vehicleaccident

Work related

Other (specify):

Describe the services received (Ex.: tests, X-rays, surgery, etc.) If necessary, continue on a separate piece of paperWhere did you receive these services?City

Canadian province or U.S. state

Country

If applicable, indicate the number of days you were hospitalized:

Amount claimed:

HEALTHCARE SERVICES IN ONTARIO

If you consulted a doctor or a specialist during the last 6 months prior to your trip, specify:

Name:

Address:

Nature of illness:

Date of last visit:Year Month Day

If you were hospitalized in Ontario during the last 6 months prior to your trip, specify:

F

1 ADDRESS 2 ADDRESS 1 ADDRESS 2

Year Month Day

Planned (if different)

Other travel insurance or Group Insurance:

Expiry date

Certificate No:

PLEASE COMPLETE AND SIGN THE FRONT OF THIS FORM

Name of the financial institution

Address for correspondence or payment (if different)No STREET

POSTAL CODE TELEPHONE

2

3

Year Month Day

Year Month Day

Card No

Name of the insurance company

Bank credit card:

OTHER INSURANCE

Complete the section below if you have other travel insurance coverage

Policy No:

REIMBURSEMENT

Canadian dollars

Other currency (specify):

Currency:

No

Yes

Were bills paid?

Totally

Partially:

If yes, please specify:

Paid amount

Nature of illness:

Name and address of hospital :

File Number :

TELEPHONE - CELLPHONE

CONTRACT HOLDER DETAILS

NAME OF THE EMPLOYER

LAST NAME (as appearing on health insurance card) FIRST NAME (as appearing on health insurance card)

Apt.

Apt.

List all medication(s) taken in the 6 months prior to your trip.: